Nursing students’ attitudes and beliefs regarding sexual healthcare in Ethiopia: An online cross-sectional study

Background Unresolved sexual issues can have an impact on a person’s wellbeing, social interactions, or even medication compliance. Given the enormous global demand to enhance and preserve sexual health, faculty members have a specific goal of developing nursing workforce who are truly prepared to work with clients who have sexual health issues. Hence, the study’s purpose has been to evaluate the current state of attitude and belief of nursing students toward sexual healthcare and the factors that influence it in Southwest Ethiopia. Methods An online cross-sectional survey was conducted in Mizan-Tepi University involving 134 undergraduate nursing students from February 1 to March 10, 2022. The Sexual Attitude and Beliefs Scale (SABS) were used to assess the level of attitudes and beliefs regarding sexual care. Statistical Package for Social Science (SPSS) Version 26 was employed for data analysis. Multivariable linear regression analyses was conducted to identify predictors of attitudes and beliefs regarding sexual healthcare. The significance level was set at p<0.05. Results The mean age of the nursing students participating in this study was 28.47±5.2. In our study, mean SABS score of the nursing students was found as 42.3 ± 2.1. The mean score of the SABS items ranged from 1.68±0.93 to 4.37±1.48. Having receiving sexual health education (p<0.001) was significantly associated with attitude and beliefs regarding sexual healthcare. Conclusions Ethiopian nursing students have been found to have a negative attitude and beliefs about sexual health care. Because comprehensive sex education is sorely lacking in nursing schools, this scrutiny prevents student nurses from receiving an adequate education. As there is a lack of appropriate sexual health subject matter, it is critical to standardize sexual health education in nursing programs so that nursing students can learn to provide comprehensive care to clients.

Introduction Sexual health defined as: "Physical, emotional, and social well-being that relates to one's sexuality" [1]. Sexual identity, maturity level, personality traits, religious and cultural affiliations all have an impact on how each client defines their sexuality and sexual health [2]. Because of society's current aversion to discussing sexuality, most women have been disheartened from vigorously interacting with their own sexual issues or communicating with healthcare providers [3].
It is the nurse's responsibility to provide sexual health services to patients in order to improve people's lives [4]. Nurse-led sexuality discussions allow patients to discuss their feelings openly while maintaining a high degree of satisfaction between the nurses and the patients [5]. Nurse practitioner applications include "evaluation of the individuals' sexual health and disclosure of their sexual concerns," as per the American Nursing Association [6].
Most nursing professionals recognize that they play a key role in sexual health care, and there is widespread agreement on the importance of incorporating sexual health education as an indispensable part of the healthcare [7]. Nonetheless, the preparation and eagerness to deal with it in practice appear to be limited [8]. Student nurses were unprepared to participate in sexual healthcare, and few of those polled thought they were skilled to communicate, guide, or create conversations regarding sexual topics [9].
According to sexuality studies, clients were prepared to tell nursing staff about their sex issues; regrettably, nurse practitioners were ineffective in sexual healthcare because their understanding of sexual care was inadequate and their perceptions of sexual healthcare were incorrect [10,11]. Unresolved sexual issues can have an impact on a person's wellbeing, social interactions, or even medication compliance [12]. As a result of ignoring sexual healthcare needs and failing to provide effective and efficient services, there is a high rate of premature mortality and morbidity [13].
Recognizing nurses' beliefs and attitudes toward sexuality issues in patients is critical for tailoring initiatives that could enhance their involvement in affective-sexual teaching, which has been shown to have a significant impact on patients [14]. As a result, it is critical for health practitioners to understand their own sexuality values and principles, as well as how they may impact the delivery of comprehensive healthcare [15].
Given the enormous global demand to enhance and preserve sexual health, faculty members have a specific goal of developing nursing workforce who are truly prepared to work with clients who have sexual health issues [16]. As a result, it is critical that student nurses receive adequate knowledge as part of their curriculum in order to work with patients who have sexual health issues [17].
Despite the benefits of recognizing healthcare providers' attitudes, there is a scarcity of research in this field, with the majority of studies focused on medical graduates and general practitioners [18][19][20]. The vast majority of research on nurses' beliefs and attitudes toward client sexual healthcare has been conducted in Western cultural contexts. Because of differences in culture, Ethiopian nursing student's attitudes and beliefs about sexual healthcare may differ from those of their Western counterparts. As a result, it's crucial to know Ethiopian nursing students' attitudes and beliefs about sexual healthcare. This is the first study in Ethiopia to assess nursing students' attitudes and beliefs about sexual health care. As a result, the study's aim was to assess nursing students' current attitudes and beliefs about sexual health care in Southwest Ethiopia, as well as the factors that influence it.

Study design
A cross-sectional online survey study was conducted at Mizan-Tepi University from February 1 to March 10, 2022.

Study setting
Mizan-Tepi University, situated in Ethiopia's southwest, has been one of the nation's best known higher education institutions. The College of Medicine and Health Sciences, which encompasses the departments of Nursing, Medicine, Public Health, Pharmacy, Medical Laboratory Sciences, Midwifery, and Biomedical Sciences, is one of its three campuses. Nursing department has regular, post basic as well as summer programs.

Study population
The study included all Mizan-Tepi University baccalaureate nursing students who have been capable and willing to give a response to online survey, and also students with one clinical area attachment experience.

Sample size determination
The sample size was determined using G power 3.1. For multiple regression analysis, a minimum sample size of 134 participants was necessary (effect size 0.15, significance level 0.05, and power of 0.80). We gathered information from 134 nursing students, allowing for a 5% nonresponse rate.

Sampling technique
The respondents were chosen using a non-probability sampling method that combined purposive and snowball sampling.

Data collection tools
The pretested questionnaire was created on Google Forms after a review of various types of literature. The questionnaire is divided into three sections; socio-demographic attributes, Participants' status of providing sexual healthcare, and "Sexual Attitude and Beliefs Scale" (SABS). Socio-demographic characteristics includes age, sex, nursing year, program, residence, mother educational status and father educational status. Participant's status of providing sexual healthcare includes the first word that comes to mind when sexuality is mentioned, with whom sexuality is discussed, status of receiving sexual health education, status of clinical sexual health evaluation and causes of not being able to make clinical evaluation. Those issues explained individual understanding of sexuality and sexual healthcare. "The SABS scale consists of 12 items. Participants make markings on a 6 (six)-point Likert type scale for each item ranging from 1 = strongly agree to 6 = strongly disagree. Each item of the scale is evaluated separately. Six of the 12 items (1, 2, 4, 6, 8, 10, 12 items) are scored inversely to avoid bias that can occur when marking the scale. The total score of the scale ranges from 12 to 72. Both the total scale score and the high item scores indicate that the negative attitudes and beliefs regarding sexual health care have increased. Increase in negative attitudes and beliefs also negatively affects the ability of the nurses to assess the sexual problem of the individual and counsel accordingly" [11].
Data quality was ensured during collection, entry, and analysis. The tool's validity was verified using face validity. The tool was pretested on 10% (14 nursing students) of the actual sample size in the Aman Health Science College 1 week before the actual data collection period and necessary correction have been made to the tool. To ensure consistency, the researcher used English version questionnaire since all the participants were literate. The results showed that the Cronbach's alpha of the overall SABS was 0.81, which was reliable.

Data collection procedures
The nursing department gave us the phone numbers of each class's representatives, and we explained the research's goals. Having followed that, we used Telegram to send the link to the representatives of each student group, utilizing their contact information. The delegate of each class then communicated the link to their group's common Telegram location using the purposive sampling method. Using the snowball sampling, students who saw the link in the common Telegram channel send it to their friends through email, and Facebook.

Operational definition
Sexual attitude and beliefs. "Nursing students Sexual Attitude and Beliefs was measured using 12 items on a 6-point Likert scale with value ranging from 12 to 72. The high item scores indicate that the negative attitudes and beliefs regarding sexual health care have increased" [11].

Data processing and analysis
The data from Google Forms in CSV format was exported to SPSS version 26.0 for analysis. To summarize the data, descriptive and inferential were used. Initially, bivariate linear regression was used to investigate the relationship between attitudes and beliefs about sexual health care and explanatory variables. The explanatory variables are selected from sociodemographic and individual status of proving sexual healthcare variables. Multiple linear regression candidates were variables with p <0.25 in bivariate linear regression. The statistical significance level was set at P<0.05. The assumptions of multiple linear regression were tested prior to analyzing the results. The Kolmogorov-Smirnov test confirmed the normality assumption.
The assumption of collinearity was tested using the variance inflation factor (VIF), which had a VIF of less than 5.

Ethics approval and consent to participate
Approval was granted by the Mizan-Tepi University College of Medicine and Health Sciences Ethics Committee immediately before inquiry. All departmental chiefs were approached. Identities as well as private labels have been eliminated from the layers and findings to protect privacy. The participants were notified of the nature of the project, the perks of the research undertaking, and their right to leave at any time. All the participants provided written informed consent. All of these strategies were conducted in compliance with the standards and rules of the manuscript.

Socio-demographic characteristics
The mean age of the nursing students was 28.47 ± 5.2 (min = 20 and max = 45) years. Of these students, 69.4% were male, 50.0% were 4 th year, and 44.8% lived in the district. Of their mothers, 67.2.7% were illiterate and of their fathers, 76.9.7% were literate (Table 1).
Participants' status of providing sexual healthcare 26.9% of nursing students defined sexuality as expressions of "family continuation/reproduction/marriage." Only 26.9% of students earned sexual education, while 78.4% overlooked sexual health in clinical settings. Most nursing students avert providing sexual healthcare for two reasons: they are embarrassed to do so (58.2%), and they believe it is not their responsibility (23.9%). Furthermore, 46.3% discussed sexual problems primarily with their mates ( Table 2).

The level of attitude and belief regarding sexual healthcare
The total SABS score was 42.3 ± 2.1 and the mean scores of the items ranged from 1.68 ± 0.93 to 4.37 ± 1.48. In practice, a high SABS score demonstrated negative attitudes and beliefs towards to the clients' sexuality issues. The major obstacles to sexual health care were "making time to discuss sexual concerns" (item 6, mean 4.19), being "comfortable talking about sexual issues" (item 4, mean 4.37) and "level of understanding how patients' diseases and treatments might affect their sexuality" (item 2, mean 4.27). One of the least significant barriers was assuming that "discussing sexuality is influential in patients' healthcare outcomes" (item 1, mean 1.68), being "uncomfortable talking about sexual issues" (item 3, mean 2.50) and "when patients ask sex-related question, they advise them to discuss it with their physician" (item 7, mean 2.66) ( Table 3).

Factors associated with attitude and belief regarding sexual healthcare
Multivariable linear regression analyses revealed factors associated with sexual attitude and beliefs among nursing students. In a bivariate linear regression, father educational status, with

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whom sexuality is discussed, and status of receiving sexual health education were found to be substantially associated with attitude and beliefs regarding sexual healthcare among nursing students at p<0.25. To investigate factors related to attitude and beliefs regarding sexual healthcare, independent variables with p<0.25 in the bivariate linear regression analysis were added to the multivariable linear regression analysis. At a significance level of 0.05, the backward elimination approach was used to choose the variables for the final model. The findings revealed that status of receiving sexual health education was significantly associated with attitude and beliefs regarding sexual healthcare among nursing students. Accordingly, having receiving education in sexual health decreased negative attitude and beliefs Thinking that the patient will not take it serious 8 6.0 The patient is old 8 6.0 Patient is single 8 6.0 Thinking that it is not my responsibility 32 23.9 https://doi.org/10.1371/journal.pone.0278760.t002 Table 3. Attitudes and beliefs of nursing students regarding sexual healthcare (n = 134).

Minimum Maximum
"Discussing sexuality is essential to patients' health outcomes" regarding sexual healthcare by -1.949 times compared to those who didn't receive any education in sexual healthcare (β = -1.949, p <0.001) ( Table 4).

Discussion
The total mean SABS score was 42.3.08 ± 2.1, which indicated negative attitudes and beliefs toward sexual healthcare. Negative attitudes and beliefs can impair student nurses' capability to analyze and consult with people who have sexuality concerns. The SABS total score of the nursing students in this study was similar with a study conducted in Turkey (42.29±3.65) [21]. The finding was higher than studies conducted in Turkey (38.03 ± 8.3) [22], Indonesia (38.04 ± 6.19) [23], Canada (37.48 ± 8.19) [24] and Sweden (40.7 ± 7.8) [25]. These findings suggest that, in comparison to developed nations, our country still has social taboos surrounding sexuality. As a result, this evidence explains why our country's nursing students are unable to properly analyze their patients' sexual health, implying that it is a barrier to care provision. In contrast, the current finding was lower than Chinese nurses (45.83 ± 8.14) [26]. Confucius' teachings have had a significant impact on Chinese thought and culture [27]. According to Confucian philosophy, sexuality is perceived as a solely reproductive role, and discussing sexual problems outside of the married couple is extremely insulting [28]. As a result, conservative attitudes against sexuality concerns are able to impact Chinese nurses' discipline [26].
First most significant barrier for nursing students when offering sexual healthcare was "feeling more comfortable discussing the patients' sexual issues with their colleagues.' The finding was similar to a study conducted in Turkey [22]. According to the current study, nursing students were generally uneasy and reluctant to provide sexual healthcare due to feelings of shyness about providing sexual healthcare and the belief that it was not their responsibility. As a result, student nurses must obtain sexual health education in order to become more cognizant of their own attitudes and beliefs regarding sexuality issues.
Numerous factors determine nurses' and nursing students' attitude and belief of sexual healthcare. This study found that those nursing students who didn't receive sexual healthcare education had more negative attitudes and beliefs regarding sexual healthcare. In other words, it was found that nursing students who received sexual healthcare education faced very few challenges while providing sexual care counselling services to their clients. This finding is similar with studies conducted in Turkey [22,29], Finland [30], Sweden [25], and China [31].
The findings of this study demonstrated no significant relation between sex, and nursing year with attitude and belief regarding sexual healthcare. In contrast, studies revealed that

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being female [15,21,22] and being first year student [22] had negative attitude and belief toward sexual healthcare. The current study has some limitations. The study relied on student nurses' self-reported data, which could lead to social desirability bias. Selection bias as a result of sampling techniques used necessitates a careful interpretation of the results. Furthermore, the investigation only included student nurses from a single organization, which may limit the study's generalizability to student nurses throughout Ethiopia as well as students from other fields of study at the same institution. Because the study was cross-sectional, it was impossible to determine causation.

Conclusions
Ethiopian nursing students have been found to have a negative attitude and beliefs about sexual health care. Because comprehensive sex education is sorely lacking in nursing schools, this scrutiny prevents student nurses from receiving an adequate education. As there is a lack of appropriate sexual health subject matter, it is critical to standardize sexual health education in nursing programs so that nursing students can learn to provide comprehensive care to clients. Quite consistent and systematic sexual education in nursing programs is desperately required such that new graduates can confront sexual issues in professional manner and conveniently that reflect their clients' high standards and trust factor. To ascertain cause-and-effect connections, an experimental study with such a larger sample is needed.